Provider Demographics
NPI:1073582656
Name:SID PETERSON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:SID PETERSON MEMORIAL HOSPITAL
Other - Org Name:PETERSON HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-258-7632
Mailing Address - Street 1:551 HILL COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-6085
Mailing Address - Country:US
Mailing Address - Phone:830-257-3111
Mailing Address - Fax:830-896-5859
Practice Address - Street 1:250 CULLY DR
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5950
Practice Address - Country:US
Practice Address - Phone:830-258-7400
Practice Address - Fax:830-896-5859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX002114251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091526602Medicaid
TX002114OtherTEXAS HEALTH AND HUMAN SERVICES COMMISSION